Provider Demographics
NPI:1013003300
Name:NURIDDIN, AHMAD IBN (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMAD
Middle Name:IBN
Last Name:NURIDDIN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1040 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9072
Mailing Address - Country:US
Mailing Address - Phone:770-474-7287
Mailing Address - Fax:770-389-3713
Practice Address - Street 1:1040 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9072
Practice Address - Country:US
Practice Address - Phone:770-474-7287
Practice Address - Fax:770-389-3713
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA055150208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA918927391BMedicaid
GA511I020107Medicare PIN